CORR Insights®: Does Medical Students’ Sense of Belonging Affect Their Interest in Orthopaedic Surgery Careers? A Qualitative Investigation

Where Are We Now?

Diversity in the healthcare workforce is associated with greater cultural competence [2], increased capacity to address healthcare disparities [5], and improved patient satisfaction with care encounters [13]. Despite robust data highlighting the value of a diverse workforce, orthopaedics remains the least diverse specialty in terms of gender [4] and one of the least diverse specialties in terms of race [1], with less known about other important factors like socioeconomic background or sexual orientation.

Yet this is old news. We have known for decades that the orthopaedic surgery workforce needs to look less like a men’s rugby team and more like the American population at large. Indeed, there are anecdotes about a lack of female representation in orthopaedics from when I was in preschool [7]. The scope of the problem and the implications related to care quality and accessibility have been extensively described [4, 11]. It is time to find solutions.

The present study by Gerull et al. [3] takes a step in that direction by providing some answers to the question, “how can we diversify the pool of medical students interested in orthopaedic surgery?” Through the lens of social belonging, Gerull et al. [3] puts into concrete terms, directly from medical students, what many of us have seen firsthand: Orthopaedic surgery is associated with the “white male athlete” stereotype, and this can divide students into an “in-group” and “out-group.” In their survey of 23 medical students, students who felt like they belonged—the “in-group”—were more likely to pursue orthopaedic experiences, which subsequently strengthened their identify alignment with orthopaedics. Conversely, those who felt like they did not belong—the “out-group”—often chose other specialties because they perceived a lack of fit within the specialty, not necessarily because of a lack of interest in orthopaedic surgery itself [3]. They highlight the cyclical nature of this process: stereotypes are self-perpetuating, not self-eradicating. Barriers highlighted by the “out-group” include a perceived lack of cultural fit, self-doubt, a lack of support and encouragement, and a sense of sacrificing one’s core identity.

Based on these findings, Gerull et al. [3] propose areas where targeted interventions to nurture belonging are warranted. Of note, the findings were not all grim. Some students— “trailblazers”—expressed a desire to break down belonging-related obstacles despite being in the “out-group.” As one student said, it’s about being “a part of the change you want to see” [3].

Where Do We Need To Go?

The question is, what changes do we (as a specialty) want to see? More importantly, what changes do we need to improve care for our patients?

Breaking down belonging-related barriers seems like a reasonable first step. Indeed, the lack of diversity in orthopaedics is multifactorial, but as the work in the current study suggests, social belonging (or a lack thereof) is a key contributing factor to a medical student’s interest in orthopaedics, separate from an academic interest in muscles, bones, or surgery. But many questions remain on the topic of social belonging, and the results of Gerull et al. [3] suggest that answering them might help us make our specialty more diverse. How can faculty, residents, and residency program leadership best promote a sense of belonging in medical students? What are we doing wrong? What can we do better? Further studies aiming to answer these questions will undoubtedly be helpful to our field and to our patients.

How Do We Get There?

The real value of studies like this one [3] is in identifying areas where targeted interventions can improve a sense of belonging. Successful interventions in these areas would theoretically cultivate more interest in orthopaedics among those in the “out-group.”

One of these areas is overcoming the orthopaedic surgeon stereotype. This process starts early, long before medical school. But how do you tackle a stereotype? Indeed, fixing problems like periprosthetic joint infection or mid-flexion instability starts to seem far less daunting in the face of trying to eradicate long-entrenched stereotypes. Social media campaigns like #ILookLikeASurgeon, an online campaign celebrating women in surgery, aim to achieve this very goal [9]. Other social media campaigns like #speakuportho take a complementary approach by increasing awareness of bias, inequities, and harassment within orthopaedic surgery. Time will tell if campaigns like these can change the perceptions of students considering a career in medicine and surgery in particular, or in the case of #speakuportho, counteract some of the darker sides of orthopaedic surgery.

Another area ripe for intervention is medical school curricula. Recent work by Rahman et al. [12] showed that medical students’ negative perceptions about orthopaedics can be largely mitigated by a clinical rotation in orthopaedics. Unfortunately, most medical schools do not have a mandatory orthopaedics rotation [6]. This is an area where our specialty has work to do in collaboration with medical school administrators and other specialties. As the senior author of the study by Rahman et al pointed out, “we need to remain committed and be intentional about pathway programs, mentoring, and changing the demographics in orthopaedics over time” [8]. If exposure to surgical subspecialties like orthopaedics is limited or nonexistent, perhaps we need to reevaluate how we are communicating the importance of this experience and how we can better incorporate this into standard practice among academic orthopaedic departments.

In addition to advocating for a required orthopaedic rotation, we need to ensure that the rotations themselves achieve all the goals previously discussed. This is where the work really begins. Time in medical school is valuable, and even one week on an orthopaedics rotation is an opportunity not to be wasted. This is the chance to counter the stereotype, cultivate belonging, and intentionally address barriers those in the “out-group” may feel. Face time with medical students on rotations can allow the “out-groupers” and “trailblazers” a chance to grow their interest and articulate their reservations about belonging to residents, fellows, and attendings. To this end, it is incumbent upon orthopaedic surgeons to give medical students space to discuss these sentiments, lest we shun an “out-grouper” away.

This is also an opportunity for attendings and residents to go out of their way to mentor medical students—especially those who might fit some of the “out-group” definitions—to help those students spark and maintain an interest in orthopaedics. I remember well my own mandatory orthopaedics rotation as a third-year medical student. While I entered medical school with an interest in orthopaedic surgery, I remember that it was in this 1-week rotation that I met one of my career mentors (Dr. Joseph Bernstein, of CORR’s “Not the Last Word” fame). Perhaps more relevant to this discussion, I specifically remember that Dr. Bernstein served as a mentor to many people in my class, including some who may have fit the “out-group” characteristics mentioned in the present study. One of those people—a female in my medical school class—is now one of my senior residents. This highlights the fact that mentors—regardless of whether they come from the “in-group” or the “out-group”—have a duty to support medical students. It cannot just fall on the shoulders of mentors from nonstereotypical backgrounds. Taking this a step further, there is also a growing push not just for mentorship, but for sponsorship. As stated in a recent AAOS Now article, “mentors advise, whereas sponsors advocate” [10]. Although mentorship is important, sponsorship —actively using power and influence for the sponsored—is arguably more necessary.

Programs like the Perry Initiative [6] and Nth Dimensions [8], as well as premedical and medical student affinity organizations associated with underrepresented groups, can also promote positive identify alignment among out-group members. These programs offer forums for creating space to talk about out-group barriers, increasing visibility of orthopaedic faculty from diverse backgrounds, and promoting allyship and mentorship.

On a personal note, as a white man who played rugby in college, I acknowledge that my path into orthopaedic surgery was wholly driven by my own sense of belonging in the field. And, admittedly, the quotes from medical students about their lack of belonging made me question whether I had directly or indirectly led to a medical student or college student feeling like they did not belong. But these quotes served as a necessary reminder that I have much to learn about how I can be better at cultivating belonging in others, in the hopes of breaking down cyclical stereotypes, not perpetuating them.